Provider Demographics
NPI:1548322639
Name:GALLAGHER, J RICHARD (M D)
Entity type:Individual
Prefix:
First Name:J RICHARD
Middle Name:
Last Name:GALLAGHER
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2114 DEERPATH RD STE 2
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-7945
Mailing Address - Country:US
Mailing Address - Phone:630-907-0010
Mailing Address - Fax:630-907-0023
Practice Address - Street 1:2114 DEERPATH RD STE 2
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-7945
Practice Address - Country:US
Practice Address - Phone:630-907-0010
Practice Address - Fax:630-907-0023
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-0411742084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL204858OtherUNITED HEALTH CARE
IL280933OtherVALUE OPTIONS
IL4658415OtherAETNA
IL036-041174Medicaid
IL4500426OtherBLUE CROSS BLUE SHIELD
IL312760Medicare ID - Type UnspecifiedMEDICARE